Superintendent’s Regulation 4400-R Exhibit 1
School Field Trip Planning Form
Instructions
All information on this form must be completed before giving the form to the Principal, School Chief and/or Superintendent. Approval is given once all required signatures are obtained.
Medical consent forms must should be completed by parents/guardian and provided to the school nurse at least 7 days before the field trip or walking trip each school year.
For day trips within the City of Rochester or within 60 miles of Rochester, the School Principal should approve the trip at least 15 days before the trip. If special circumstances arise, the Principal may, in his/her discretion, approve a trip wherein the school field trip planning form is not submitted at least 15 days before the trip. However, in all cases, a School Trip Planning Form must be completed and approved by the Principal prior to the trip.
For trips 60 miles or farther from downtown Rochester, and for all overnight trips regardless of distance, all information requested on this form must approved by the Principal at least 60 days before the trip and by the School Chief at least 45 days before the trip.
For all international trips, the trip must be approved by the Principal at least 180 days before the trip, by the School Chief at least 150 days before the trip, and by the Superintendent at least 120 days before the trip.
Required Information
Name of Person Submitting the Form ______Title______
School ______
Class(es) Attending Trip ______Student Grade Level______
(use classroom teacher’s last name)
Anticipated Number of Students on Trip: Total______Male Female
Destination ______
Date(s) of the Trip ______
Anticipated Transportation Method
Cost per student $__Total Cost $______Funding Source______
Educational Purpose Statement: Please provide a detailed statement outlining the educational purpose of the proposed school field trip. (Attached an additional sheet(s)
Itinerary: Please provide a detailed itinerary for the trip
Parent/Guardian Letter: Please attach a draft of the parent/guardian letter explaining the trip.
Parental Notification/Consent Form: Please attach the Parent Notification/Consent form specific to the trip.
List of Chaperones: Please attach a list of chaperones. The chaperone information should include the name, title and gender of the chaperones. (The ratio of students to chaperones must conform to Superintendent’s RegulationSchool Field Trips 4400-R Section III E).
Approved by Principal Date _____ (All Trips)
Approved by School Chief Date ______
(Overnight and trips at least 60 miles from Rochester)
Approved by the Superintendent ___Date (International Trips Only)
Superintendent Regulation 4400-R Exhibit 2
FIELD TRIP INFORMATION FORM
TRIP INFORMATION (Completed by School)
Trip Date(s): ______Trip Supervisor: ______
Destination:______Departure Site: ______
Departure Date and Time: Return Date and Time:
Return Site:
Among other activities, this trip may include the following physical or sports activities
______
______
Clothing/Equipment Expected for this Trip: ______
STUDENT INFORMATION(Completed by Parent or Guardian)
Name: ______
Address: ______
City: ______State: ______Zip Code: ______
Birth Date: ______
Gender: [ ] Male [ ] Female Student Cell Phone Number:
PARENT OR GUARDIAN INFORMATION (Completed by Parent or Guardian)
Name: ______
Address: ______
City: ______State:______Zip Code: ______
Home Telephone: ( ) ______Work Telephone: ( ) ______
Cell Telephone: ( ) ______Email Address: ______
Emergency Contact Name: ______Relationship______
Emergency Contact Person’s Number: ______
This form is the property of the RochesterCitySchool District (“RCSD”) and should not be used if the school field trip is not authorized and approved by the RCSD. It may not be modified and must be completed in full to be processed and approved.
FIELD AND WALKING TRIP MEDICAL CONSENT FORM FOR ______SCHOOL YEARParents/guardians must complete and return this form to the school nurse at least 7 days before the first field trip or walking trip of each school year and update this form if their child’s medical condition changes
Student Name / Date of Birth
Street Address with Zip Code / Doctor’s Name
Home Telephone / Doctor’s Telephone Number
Insurance Carrier’s Name / Insurance Identification Number
STUDENT’S HEALTH STATUS
Does your child have any current health problems? (Please check all that apply and tell us about them):
____Allergies (that requires emergency medicine)____Asthma/Breathing problems
____Cardiac (Heart) problems ____Diabetes
____Seizure Disorder ____Bones or Joints
____Bee sting (that requires emergency medicine)____Other problems?
Please tell us more about the problem(s)
MEDICINES
**The school nurse must have a current doctor’s order for medicine on file in order for your child to take medicine on the trip. Please contact your child’s school nurse to make sure all medical forms are completed.
Medication that needs to be taken on the Field Trip:
_____ (initials) My child doesn’t need any medication on field trips for this school year.
I give permission to a physician or hospital to secure proper treatment including (but not limited to) medications, injections, anesthesia or surgery for my child as named above.
This health information is accurate and correct insofar as I know. My child has permission to engage in all activities except as noted above. In the event that I cannot be reached in an emergency, I authorize the school and/or its agents to authorize the treatment recommended by the health careprovider available to render treatment. This authorization shall also extend to and include hospitalization for first aid where/when necessary. I understand that I will be responsible for the cost of all medical treatment render in connection with the trip.
Parent / Guardian Signature Date
For School Nurse Use Only
No Concerns______Needs nurse to attend______No doctor orders/note ______See nurse 24/48hrs before trip______
Students Ability to Administer Medication: ______Self-administration ______Non-Self administration
Medical/Emergency Care Plan: ______Yes (if so please provide plan)______No
Parent input:______
______
______
Nurse signature Date
This form is the property of the Rochester City School District (“RCSD”) and should not be used if the school field trip is not authorized and approved by the RCSD. It may not be modified and must be completed in full to be processed and approved.
This form is available on the WEB at on the “Health Services Forms for Parents” link.
SNS/Field Trip - Emergency Medical Info
WALKING TRIP CONSENT FORM
I ______,the parent/guardian of ______(student’s name)
hereby give my permission for my child to participate in regular walking trips to and from:
______throughout the school year and agree to the following conditions:
a) I understand that there are possible risks related to this trip and I consent to my child’s participation in all trip activities.
b) I have accurately completed and updated the Medical Consent information for my child.
c) I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
d) I understand that my child is expected to behave responsibly and to follow the school’s code of conduct. I agree and understand that I am responsible for the actions of my child.
e) I understand that my child shall be accompanied by one or more staff member(s) during the walking trip.
f) I give my permission for my child to participate in this walking trip.
I certify that I have read and I understand this release and agree to its provisions.
______
Student SignatureDate
I certify that I am the parent or legal guardian of the student named above and that I have read and understand this consent form.
______
Parent/Guardian SignatureDate
This form is the property of the Rochester City School District (“RCSD”) and should not be used if the school field trip is not authorized and approved by the RCSD. It may not be modified and must be completed in full to be processed and approved.
FIELD TRIP CONSENT FORM
I ______,the parent/guardian of ______(student’s name)
hereby give my permission for my child to take part in the school trip described below:
______and agree to the
following conditions:
a) I understand that there are potential risks associated with this trip and I consent to my child’s participation in all trip activities.
b) I acknowledge that I have accurately filled out the Medical Consent information provided to me.
c) I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
d) I understand that my child is expected to behave responsibly and to follow the school’s code of conduct. I agree and understand that I am responsible for the actions of my child.
e) I understand that I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child shall be accompanied by staff member(s) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site.
f)The program organizers and/or group chaperones may make reasonable changes in the dates, destinations, or itinerary for the mutual benefit and safety of group participants. In such event, they shall not be liable for any delay, loss, or damage resulting therein. In the event of any illness, accident, or incapacity incurred by my child, the group chaperone may consider my child’s best interests in securing medical treatment, hospitalization, medication and/or return transportation at my own expense.
g) I give my permission for my child to participate in this school trip.
I certify that I have read and I understand this release and agree to abide by its provisions.
______
Student SignatureDate
I certify that I am the parent or legal guardian of the student named above and that I have read and understand this consent form.
______
Parent/Guardian SignatureDate
This form is the property of the Rochester City School District (“RCSD”) and should not be used if the school field trip is not authorized and approved by the RCSD. It may not be modified and must be completed in full to be processed and approved.
INTERNATIONAL WAIVER AND RELEASE FORM
______(Insert name of Trip)
I ______am the parent/guardian of __.
I hereby request the Rochester City School District to permit ______to participate in the , sponsored, in part, by the Rochester City School District.
It is impossible to eliminate all risk involved in international travel. For example, there are risks associated with air travel, local transportation systems, political unrest, and many other factors that are outside of the control of the RochesterCitySchool District. The risks can range in severity from minor to serious and could include even death. Iacknowledge that I have read and understand any travel advisory issued by the United States Department of State and give permission for my son/daughter to travel to ______with the ______.
a) I understand that there are potential risks associated with this trip and I consent to my child’s participation in all trip activities.
b) I have accurately completed and updated the Medical Consent Form provided to me.
c) I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my child’s behalf and at my expense in obtaining medical treatment for my child.
d) I understand that my child is expected to behave responsibly and to follow the school’s Code of Conduct. I agree and understand that I am responsible for the actions of my child.
e) I understand that I am responsible for getting my child to and from the departure and return sites. I understand that my child shall be accompanied by staff member(s) during the trip, including while traveling from the departure site to the destination, and from the destination to the return site.
f)The program organizers and/or group chaperones may make reasonable changes in the dates, destinations, or itinerary for the mutual benefit and safety of group participants. In such event, they shall not be liable for any delay, loss, or damage resulting therein.
g) I give my permission for my child to participate in this international trip.
I have been provided the opportunity to review and consider this International Consent Form before signing it and understand what it says.
______
Signature of Parent or Guardian Date
Subscribed and sworn to before me
this day of ___ , 20___
Notary Public
______
Signature of StudentDate
This form is the property of the Rochester City School District (“RCSD”) and should not be used if the school field trip is not authorized and approved by the RCSD. It may not be modified and must be completed in full to be processed and approved.